Immigrant Parents’ Perceived Social Support and Their Children’s Oral Health Behaviors and Caries Experience

This study examined the associations between immigrant parents’ perceived social support (PSS) and their children’s oral health behaviors (OHB) and caries experience. We recruited immigrant parents and children aged 2–12 years. Data were collected on the sociodemographic and OHB information of the children. The parents’ total PSS score and its dimensions were measured using the validated Personal Resource Questionnaire (PRQ2000). Dental examinations determined the children’s caries experience using the DMFT/dmft index. A total of 336 parents and children were included in the study. Household income predicted the parents’ PSS (B = −5.69; 95% CI −9.077, −2.32). Children of parents with higher PSS reported ≥2 toothbrushing/day (p ≤ 0.05). Among the PSS domains, parental education level predicted their social integration (B = −0.16; 95% CI −0.30, −0.02) and nurturance (B = −0.24; 95% CI −0.43, −0.06). Family income predicted social integration (B = −0.17; 95% CI −0.33 −0.01), worth (B = −0.23; 95% CI −0.39 −0.06), and assistance (B = −0.22; 95% CI −0.42 −0.01). Parents with higher scores of intimacy and social integration were more aware of their children’s oral health (p = 0.01). The parental social integration mean scores were significantly higher among parents whose children consumed ≥1 sugary snack/day (p = 0.02). All five domain scores were significantly higher among parents of children who reported ≥2 toothbrushing/day compared with children who brushed <2/day (p < 0.05). The results demonstrated that parents’ PSS only improved their children’s toothbrushing frequency. Compared to other domains, social integration was significantly associated with children’s OHB. Neither parental PSS total score nor domains were associated with DMFT/dmft.


Introduction
Oral health problems are not only the result of biological and behavioral factors; there are also sociocultural-related factors that should be taken into consideration [1][2][3]. Researchers have recently shifted toward understanding the sociocultural factors underlying oral health problems, which are known as the social determinants of oral health. Immigrant populations' oral health and wellbeing are vulnerable to many changes and challenges after their arrival in host countries, including Canada [4]. Language and cultural barriers, housing and employment problems, low socioeconomic status, and lack of medical and dental coverage are major challenges in many immigrants' lives [5][6][7].
Immigrants' oral health can be affected by changes occurring in their social life, such as a reduced number of family members in the host society due to the migration process [8][9][10]. These social ties or connections may affect immigrants' oral health and children's A total of 336 dyads of one parent and one child were included in this cross-sectional study through 20 community events. The participants were from different communities including South Asians, South East and East Asians, Arabs, Africans, East Europeans, and Hispanics. The majority of the adult participants were mothers with a mean (SD) age of 37 (6.3) years. Around 96% of the mothers were Canadian citizens or permanent residents, with a mean (SD) duration of 8 (5.8) years of living in Canada and only 4% were temporary residents. Regarding income, 42% of the families had a middle income and 67% of the mothers had a college or higher education. With regard to the children, 50.6% were female and 60.7% were born in Canada. Their mean (SD) age was 6.2 (2.8) years (Table 1).
A total of 48 of the children (48.8%) had visited a dentist within the past 12 months. The reason for their dental visit was a dental checkup in 74% of cases, and only 42% had dental coverage. The mean (SD) DMFT/dmft of the examined children was 3.7 (4.2) in a range of 0-18. About 58% of parents were aware of their child's dental cavities and 40% rated their child's oral health as "good". About 23.5% of children had one or more sugar intakes per day, and 66.1% of them brushed their teeth twice a day ( Table 2).
Length of residency in Canada was negatively correlated with the amount of sugar consumption (p-value < 0.05). Mother's age and education, family structure, income level, and dental coverage were significantly associated with increased children's dental care utilization (p-value < 0.05). Toothbrushing frequency was only significantly associated with family structure and mother's education. Foreign-born children in families with shorter residency lengths in Canada had higher DMFT/dmft scores compared to their native-born peers and families who had lived longer in Canada (p-value < 0.05). Bivariate analysis showed that parents' awareness of their children's oral health status was associated with higher DMFT/dmft levels compared to parents who were unaware (p-value < 0.05) ( Table 3).   II compared to children who consumed less than one sugary snack/day (34.31 (5.04) and 33.15 (4.92), respectively; p-value = 0.03). The mean scores of both factors were significantly higher among children who brushed twice or more a day compared with children who brushed less than twice a day (Table 7). Neither Factor I nor Factor II were significantly associated with their children's DMFT/dmft scores. Multivariate logistic regression: Binominal logistic regression was performed to ascertain the effect of parental perceived social support level and covariates on oral health behaviors. Table 8 presents the results from the three models for the association between PSS and children's toothbrushing frequency. On average, with a one-unit increase in the PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06).

Parental Perceived Social Support Total Score:
The parents' PSS total score mean (SD) was 63.327 (9.0), with a maximum level of 75. For this sample, the scale had an internal reliability coefficient (Cronbach's α) of 0.9, which indicates a high level of internal consistency; the scale items were homogeneous ( Table 2).
Length of residency in the host country, current status in Canada, mother's education, and child's dental coverage were not significantly associated with parental PSS (p-value > 0.05). Family income level was significantly associated with parents' PSS score; low-(<CAD 2000) and middle-income (CAD 2000-4000) families had lower PSS scores than higher income (>CAD 4000) families (B = −2.82; 95% CI −5.15, −0.49) ( Table 4). Multivariate logistic regression: Binominal logistic regression was performed to ascertain the effect of parental perceived social support level and covariates on oral health behaviors. Table 8 presents the results from the three models for the association between PSS and children's toothbrushing frequency. On average, with a one-unit increase in the PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06). Multivariate logistic regression: Binominal logistic regression was performed to ascertain the effect of parental perceived social support level and covariates on oral health behaviors. Table 8 presents the results from the three models for the association between PSS and children's toothbrushing frequency. On average, with a one-unit increase in the PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06). Multivariate logistic regression: Binominal logistic regression was performed to ascertain the effect of parental perceived social support level and covariates on oral health behaviors. Table 8 presents the results from the three models for the association between PSS and children's toothbrushing frequency. On average, with a one-unit increase in the PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06).  Table 8 presents the results from the three models for the association bet PSS and children's toothbrushing frequency. On average, with a one-unit increase PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06). The children of parents who perceived a higher level of social support reported toothbrushing twice or more per day compared to brushing less than twice a day (p-value ≤ 0.05) ( Table 5). The parental PSS mean scores were neither significantly associated with the other oral health behaviors nor with the DMFT/dmft scores.
Social integration and nurturance were significantly associated with parents' education level. Parents with high school education or less had lower scores of social integration and nurturance than parents with a higher education. Moreover, the social integration, worth, and assistance domains were significantly associated with parents' income level.  (Table 4). Mother's age was positively correlated with the assistance domain (p-value = 0.004).
Parents who were aware of their children's oral health had significantly higher mean (SD) scores of intimacy (12.90 (2.07); p-value = 0.01) and social integration (21.33 (3.02); p-value = 0.02) compared to parents who were unaware. In addition, the parental social integration mean (SD) scores were significantly higher among children who consumed one or more sugary snacks/day (21.35 (3.20)) compared to children who consumed less than one sugary snack/day (20.57 (2.96); p-value = 0.02). All five domain mean scores were significantly higher among the parents of children who reported toothbrushing twice or more a day compared with children who brushed less than twice a day ( Table 5). None of the parents' perceived social support domains were significantly associated with their children's DMFT/dmft scores.

Parental Perceived Social Support Factor Analysis:
In our factor analysis, according to the eigenvalues, scree plot, and parallel analysis, two factors were extracted that explained 57.5% of the total variance. Factor I consisted of eight items and Factor II contained seven items. The factors' mean (SD) scores were 29.5 (4.6) and 33.8 (5.0) for Factors I and II, respectively. The Cronbach's alpha was 0.89 for Factor I and 0.88 for Factor II. The inter-item correlations ranged from 0.38 to 0.65 for Factor I and 0.39 to 0.75 for Factor II ( Table 2).
Factor I was only significantly associated with parents' income level, with low-(<CAD 2000) and middle-income (CAD 2000-4000) families having a lower score for that factor (B = −1.60; 95% CI −2.79, −0.40) than higher income (>CAD 4000) families (Table 6). In addition, mother's age was positively correlated with Factor I (p-value = 0.03). Factor II was not associated with any demographic variables. Table 6. Association between parental perceived social support factors (PRQ2000) and demographics (B coefficient, 95% CI and p-values).

Current status in Canada
significantly higher among children who brushed twice or more a day compared w children who brushed less than twice a day (Table 7). Neither Factor I nor Factor II w significantly associated with their children's DMFT/dmft scores. Multivariate logistic regression: Binominal logistic regression was performed ascertain the effect of parental perceived social support level and covariates on oral hea behaviors. Table 8 presents the results from the three models for the association betw PSS and children's toothbrushing frequency. On average, with a one-unit increase in PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06).  33.15 (4.92), respectively; p-value = 0.03). The mean scores of both factors w significantly higher among children who brushed twice or more a day compared w children who brushed less than twice a day (Table 7). Neither Factor I nor Factor II w significantly associated with their children's DMFT/dmft scores.

Multivariate logistic regression:
Binominal logistic regression was performe ascertain the effect of parental perceived social support level and covariates on oral he behaviors. Table 8 presents the results from the three models for the association betw PSS and children's toothbrushing frequency. On average, with a one-unit increase in PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06). II compared to children who consumed less than one sugary snack/day (34.31 (5.04) and 33.15 (4.92), respectively; p-value = 0.03). The mean scores of both factors were significantly higher among children who brushed twice or more a day compared with children who brushed less than twice a day (Table 7). Neither Factor I nor Factor II were significantly associated with their children's DMFT/dmft scores. Multivariate logistic regression: Binominal logistic regression was performed to ascertain the effect of parental perceived social support level and covariates on oral health behaviors. Table 8 presents the results from the three models for the association between PSS and children's toothbrushing frequency. On average, with a one-unit increase in the PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06). II compared to children who consumed less than one sugary snack/day (34.31 (5.04 33.15 (4.92), respectively; p-value = 0.03). The mean scores of both factors significantly higher among children who brushed twice or more a day compared children who brushed less than twice a day (Table 7). Neither Factor I nor Factor II significantly associated with their children's DMFT/dmft scores. Multivariate logistic regression: Binominal logistic regression was performe ascertain the effect of parental perceived social support level and covariates on oral h behaviors. Table 8 presents the results from the three models for the association betw PSS and children's toothbrushing frequency. On average, with a one-unit increase i PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06). Parents who were aware of their children's oral health reported significantly higher mean (SD) scores of Factor II compared to parents who were unaware: 34.38 (4.84) and 32.94 (5.14), respectively (p-value = 0.01). Furthermore, parents of children who consumed one or more sugary snacks/day reported significantly higher mean (SD) scores for Factor II compared to children who consumed less than one sugary snack/day (34.31 (5.04) and 33.15 (4.92), respectively; p-value = 0.03). The mean scores of both factors were significantly higher among children who brushed twice or more a day compared with children who brushed less than twice a day (Table 7). Neither Factor I nor Factor II were significantly associated with their children's DMFT/dmft scores. Multivariate logistic regression: Binominal logistic regression was performed to ascertain the effect of parental perceived social support level and covariates on oral health behaviors. Table 8 presents the results from the three models for the association between PSS and children's toothbrushing frequency. On average, with a one-unit increase in the PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06). Table 8. Results of logistic regression analysis for the association between parents' perceived social support level and children's brushing frequency (n = 336; OR (95% CI); p-value). II compared to children who consumed less than one sugary snack/day (34.31 (5.04) and 33.15 (4.92), respectively; p-value = 0.03). The mean scores of both factors were significantly higher among children who brushed twice or more a day compared with children who brushed less than twice a day (Table 7). Neither Factor I nor Factor II were significantly associated with their children's DMFT/dmft scores. Multivariate logistic regression: Binominal logistic regression was performed to ascertain the effect of parental perceived social support level and covariates on oral health behaviors. Table 8 presents the results from the three models for the association between PSS and children's toothbrushing frequency. On average, with a one-unit increase in the PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06). II compared to children who consumed less than one sugary snack/day (34.31 (5.04) and 33.15 (4.92), respectively; p-value = 0.03). The mean scores of both factors were significantly higher among children who brushed twice or more a day compared with children who brushed less than twice a day (Table 7). Neither Factor I nor Factor II were significantly associated with their children's DMFT/dmft scores. Multivariate logistic regression: Binominal logistic regression was performed to ascertain the effect of parental perceived social support level and covariates on oral health behaviors. Table 8 presents the results from the three models for the association between PSS and children's toothbrushing frequency. On average, with a one-unit increase in the PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06). II compared to children who consumed less than one sugary snack/day (34.31 (5.04) and 33.15 (4.92), respectively; p-value = 0.03). The mean scores of both factors were significantly higher among children who brushed twice or more a day compared with children who brushed less than twice a day (Table 7). Neither Factor I nor Factor II were significantly associated with their children's DMFT/dmft scores. Multivariate logistic regression: Binominal logistic regression was performed to ascertain the effect of parental perceived social support level and covariates on oral health behaviors. Table 8 presents the results from the three models for the association between PSS and children's toothbrushing frequency. On average, with a one-unit increase in the PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06). II compared to children who consumed less than one sugary snack/day (34.31 (5.04) and 33.15 (4.92), respectively; p-value = 0.03). The mean scores of both factors were significantly higher among children who brushed twice or more a day compared with children who brushed less than twice a day (Table 7). Neither Factor I nor Factor II were significantly associated with their children's DMFT/dmft scores. Multivariate logistic regression: Binominal logistic regression was performed to ascertain the effect of parental perceived social support level and covariates on oral health behaviors. Table 8 presents the results from the three models for the association between PSS and children's toothbrushing frequency. On average, with a one-unit increase in the PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06). II compared to children who consumed less than one sugary snack/day (34.31 (5.04) and 33.15 (4.92), respectively; p-value = 0.03). The mean scores of both factors were significantly higher among children who brushed twice or more a day compared with children who brushed less than twice a day (Table 7). Neither Factor I nor Factor II were significantly associated with their children's DMFT/dmft scores. Multivariate logistic regression: Binominal logistic regression was performed to ascertain the effect of parental perceived social support level and covariates on oral health behaviors. Table 8 presents the results from the three models for the association between PSS and children's toothbrushing frequency. On average, with a one-unit increase in the PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06). Table 8. Results of logistic regression analysis for the association between parents' perceived social support level and children's brushing frequency (n = 336; OR (95% CI); p-value). II compared to children who consumed less than one sugary snack/day (34.31 (5.04) and 33.15 (4.92), respectively; p-value = 0.03). The mean scores of both factors were significantly higher among children who brushed twice or more a day compared with children who brushed less than twice a day (Table 7). Neither Factor I nor Factor II were significantly associated with their children's DMFT/dmft scores. Multivariate logistic regression: Binominal logistic regression was performed to ascertain the effect of parental perceived social support level and covariates on oral health behaviors. Table 8 presents the results from the three models for the association between PSS and children's toothbrushing frequency. On average, with a one-unit increase in the PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06). II compared to children who consumed less than one sugary snack/day (34.31 (5.04) and 33.15 (4.92), respectively; p-value = 0.03). The mean scores of both factors were significantly higher among children who brushed twice or more a day compared with children who brushed less than twice a day (Table 7). Neither Factor I nor Factor II were significantly associated with their children's DMFT/dmft scores. Multivariate logistic regression: Binominal logistic regression was performed to ascertain the effect of parental perceived social support level and covariates on oral health behaviors. Table 8 presents the results from the three models for the association between PSS and children's toothbrushing frequency. On average, with a one-unit increase in the PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.06).   Table 8 presents the results from the three models for the association PSS and children's toothbrushing frequency. On average, with a one-unit incre PSS score, toothbrushing frequency increased by 5% (OR = 1.05; 95% CI: 1.02-1.

Discussion
Social life changes faced by immigrants after moving to a new country, such as a decreased number of close family members and friends, may lead to isolation and loneliness. This may negatively affect their health and social life due to the adoption of detrimental habits as coping methods [18]. Parental social support within the host country can play a vital role in the oral health outcomes of their children. Therefore, the aim of this study was to measure the parental PSS score and determine whether it had any impact on their children's oral heath behaviors and caries experience. We hypothesized that children of parents with higher levels of PSS would have improved oral health behaviors and a lower caries experience than children of parents with lower PSS scores. Among all oral health behaviors, only children's toothbrushing frequency was significantly associated with parental PSS. With regard to demographics, family income level was significantly associated with parental PSS.
In contrast to previous studies [11,12], our results suggest that children of parents with a higher perception of social support had higher toothbrushing frequency. This could be due to an increase in the actual support that parents received, allowing them to gain more information about the importance of promoting positive oral health behaviors [18,28]. In addition, parents who perceive a high level of social support may have a greater ability to extend their relationships not only with friends and family, but also with dental professionals and community workers [18,28]. These individuals may play a vital role in increasing parental awareness and knowledge, which can have a significant impact on their children's oral health [18,28]. Moreover, children's toothbrushing frequency was associated with their mother's level of education in our study. A higher education can result in more awareness of the importance of children's oral health and toothbrushing frequency.
On the contrary, we did not find any significant associations between parental PSS score and children's sugar intake and dental care utilization. There is an inconsistency among the studies examining the associations between parents' PSS score and their children's sugar consumption and dental care utilization in the literature. While some studies reported a positive association [19,[28][29][30], others' results were more aligned with our findings [12,31]. However, in our study, children's sugar intake was positively associated with length of residency in Canada. Longer residency in the host country may lead to higher consumption of a cariogenic diet due to a broad range of factors, including socioeconomic status, neighborhood nature, and post-migration challenges that cause parents to give less priority to their children's oral health [18,32,33].
On the other hand, children's dental care utilization was linked to other factors, such as income, child's dental coverage, family structure, mother's age, and parents' education. The positive effect of income and dental coverage on dental care utilization may facilitate access to beneficial resources, dental care utilization, and improved oral health behaviors [12,27]. Family structure is another factor influencing a child's dental care utilization. Children of married parents are more likely to receive dental care than children of single parents [34]. Married parents also had higher levels of social support compared to single parents [34]. It is possible that single parents are more vulnerable to stressors and sole-parenting responsibilities compared to married ones, which could result in a lower rate of dental care utilization [27,34]. In addition, parents who are more educated may be more knowledgeable about oral health and, in turn, would foster more healthy behaviors, including more frequent use of dental services [12].
The caries rate was lower among children whose parents had lived in Canada longer. This may be a reflection of their parents' PSS score as an indirect relation, although this association did not reach the significance level. Social support has been associated positively with length of residency in the host country. In addition, a longer time of residency in the host country allows immigrants to better integrate into mainstream society and receive more benefits from the available social resources, which may result in increased knowledge and greater awareness about their children's oral health.
In our study, PSS scores were higher among high-income parents than low-income ones, which is consistent with previous studies reporting that low levels of income were associated with a lack of social support [27,35,36]. Stress, depression, and poor social skills are factors associated with post-immigration challenges such as employment and income level [35]. As a result, more limited resources and social support are available to low-income immigrant parents compared to high-income parents who have more access to and receive more support from the surrounding environment [35].
With regard to the parental PSS domains, social integration was the domain most associated with children's oral behaviors. Parents with high social integration were more aware of their children's oral health, which consequently led to increased frequency in toothbrushing in their children. This may be a reflection of reduced social strains, improved social network, and perceived social support that results in increased awareness about oral health and better oral health outcomes among their children [37]. On the contrary, increased sugar consumption was reported among children of parents with high social integration. This could be because of a shift from their traditional food to a Western diet, which includes more processed foods, fat, and added sugars [38].
Based on the Canadian Health Measures Survey (CHMS) conducted in 2007-2009, 57% of children aged 6-11 years had a combined dmft and DMFT score of at least 1 [1]. In addition, the average dmft and DMFT was 2.5 for primary or permanent teeth [1]. In our sample, we had 176 children aged 6-12 years with an average DMFT/dmft of 4.28. The average dmft of children aged 2-5 years was also 3.03. With regard to oral health behaviors, the CHMS report indicated that 91.0% of Canadian children had visited a dentist within the previous 12 months, while in our study, only 48.8% reported a dental visit in the year prior to our data collection. These findings confirm a noticeable oral health disparity between children of immigrant populations and their national-born counterparts.
To the best of our knowledge, this study was the first to adopt the Personal Resource Questionnaire (PRQ2000) (part II) in determining an association between parental PSS and children's oral health among immigrants. In addition, our study was strengthened by looking at the perceived social support in particular, rather than other types of social support, as PSS is more of a perspective measure. It represents immigrants' perceptions over a longer duration of time and can enhance adjustment to a new country by promoting positive effects, self-confidence, and a sense of personal satisfaction.
Nonetheless, some limitations of this study need to be acknowledged. First, the crosssectional design limited our study to only drawing causal inferences and only explained a snapshot of the associations examined. In addition, the implementation of the snowball sampling technique limited the generalizability of our findings, even though it is a widely used method to recruit large samples of minorities and hard-to-reach populations. The self-reported questionnaire is another limitation of our study, as the answers might be biased and more socially desirable. Finally, while our pilot results suggested that we should change the seven-point Likert scale to a five-point one to account for the participants' literacy level, this change made it difficult for us to compare our findings with those of studies that used a similar instrument, but with the suggested seven-point scale.

Conclusions
Immigrant parents' perceived social support level was associated with higher toothbrushing frequency in their children. However, it was not significantly correlated with either of the other oral health behaviors (i.e., sugar intake and dental visits). Among the five PSS domains, social integration had the strongest association with children's oral health behaviors. Neither PSS total score nor domains were significantly associated with DMFT/dmft. With regard to the two factors of social support that emerged, Factor II was significantly more associated with oral health behaviors than was Factor I.